Required when there is payment from another source. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). 19 Antivirals Dispensing and Reimbursement The table below The resulting Patient Pay Amount (505-F5) must be greater than or equal to zero. PARs are reviewed by the Department or the pharmacy benefit manager. PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER, ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER. Required if Previous Date Of Fill (530-FU) is used. Required if Reason for Service Code (439-E4) is used. Physician Administered Drugs (PAD) for medications not administered in member's home or in an LTC facility. BNR=Brand Name Required), claim will pay with DAW9. Applicable co-pay is automatically deducted from the provider's payment during claims processing. Cost-sharing for members must not exceed 5% of their monthly household income. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. RESPONSE CLAIM BILLING NONMEDICARE D PAYER SHEET Timely filing for electronic and paper claim submission is 120 days from the date of service. Drug list criteria designates the brand product as preferred, (i.e. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. If there is a marketplace shortage for the generic version of the prescribed drug and only the brand-name product is available, claim will pay with DAW 8. Testing Procedures - Alabama Medicaid Reimbursement Basis Definition Required when the patient's financial responsibility is due to the coverage gap. Pharmacies should continue to rebill until a final resolution has been reached. Required when other insurance information is available for coordination of benefits. EY Many of our standards are named in federal legislation, including HIPAA, MMA, HITECH and Meaningful Use (MU). "Required When." More information about Tamper-Resistant Prescription Pads/Paper requirements and features can be found in the Pharmacy section of the Department's website. This field explains how the drug ingredient cost was derived; whether DOJ, FUL, AWP (As of October 1, 2011, AWP pricing will no longer be available. In addition, some products are excluded from coverage and are listed in the Restricted Products section. We anticipate that our pricing file updates will be completed no later than February 1, 2021. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Figure 4.1.3.a. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER. RESPONSE CLAIM BILLING NON-MEDICARE D PAYER SHEET Pharmacies must complete third-party information on the PCF and submit documentation from the third-party payer of payment or lack of payment. If a pharmacy is made aware of eligibility after 120 days from the date of service, the pharmacy may submit the claims electronically by obtaining a PAR from the Pharmacy Support Center, or by paper using a pharmacy claim form. When a pharmacy has exhausted all authorized rebilling procedures and has not been paid for a claim, the pharmacy may submit a Request for Reconsideration to the pharmacy benefit manager. The pharmacy must retain a record of the reversal on file in the pharmacy for audit purposes. Prior authorization requests for some products may be approved based on medical necessity. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files. Stolen prescriptions will no longer require a copy of the police report to be submitted to the Department before approval will be granted. Updated Retroactive Member Eligibility, Delayed Notification to the Pharmacy of Eligibility, Extenuating Circumstances and Other Coverage Code definitions. B. Additionally, all providers entering 340B claims must be registered and active with HRSA. Required only for secondary, tertiary, etc., claims. Required if Help Desk Phone Number (550-8F) is used. In determining what drugs should be subject to prior authorization, the following criteria is used: Most brand-name drugs with a generic therapeutic equivalent are not covered by the Health First Colorado program. 03 =Amount Attributed to Sales Tax (523-FN) NCPDP Telecommunication Standard Version/Release #: Provider Relations Help Desk Information: NCPDP Telecommunication version 5.1 until TBD. Providers can collect co-pay from the member at the time of service or establish other payment methods. AMOUNT EXCEEDING PERIODIC BENEFIT MAXIMUM. Required if this field could result in contractually agreed upon payment. The Request for Reconsideration Form and instructions are available in the Provider Services Forms section of the Department website. PB 18-08 340B Claim Submission Requirements and Durable Medical Equipment (DME), these must be billed as a medical benefit on a professional claim. 08 = Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM) This pharmacy billing manual explains many of the Colorado Department of Health Care Policy & Financing's (the Department) policies regarding billing, provider responsibilities, and program benefits. Web Basis of Cost Determination should be submitted with the value 15 (Free product at no associated cost). Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. AMOUNT ATTRIBUTED TO PROVIDER NETWORK SELECTION. Required if Other Payer patient Responsibility Amount (352-NQ) is submitted. DAW code: 1-Prescriber requests brand, contact MRx at 18004245725 for override. WebThe Compound Ingredient Basis of Cost Determination field (490-UE), should equal 09 (Other) to identify the ingredient that would normally be assigned a KP modifier. Required when this field could result in different coverage, pricing, patient financial responsibility, and/or drug utilization review outcome. NCPDP VERSION 5 PAYER SHEET B1/B3 Transactions - DOL Testing Procedures - Alabama Medicaid The Health First Colorado program does not pay a compounding fee. If the PAR is approved, the pharmacy has 120 days from the date the member was granted backdated eligibility to submit claims. Quantity Prescribed (Field # 460-ET) for ALL DEA Schedule II prescription drugs, regardless of incremental or full-quantity fills, Quantity Intended To Be Dispensed (Field # 344-HF), Days Supply Intended To Be Dispensed (Field # 345-HG). RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required if this field is reporting a contractually agreed upon payment. Required when Flat Sales Tax Amount Submitted (481-HA) is greater than zero (0) or when Flat Sales Tax Amount Paid (558-AW) is used to arrive at the final reimbursement. Required when Additional Message Information (526-FQ) is used. Required if needed for reversals when multiple fills of the same Prescription/Service Reference Number (402-D2) occur on the same day. Required when Percentage Sales Tax Amount Paid (559-AX) is greater than zero (0). 1 = Proof of eligibility unknown or unavailable. Prescriptions generally cannot be dispensed in quantities less than the physician ordered unless the quantity ordered is more than a 100-day supply for maintenance medications or more than a 30-day supply for non-maintenance medications. 677 0 obj <>stream Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. Required when there is payment from another source. Pharmacy Billing Procedures and Forms section of the Department's website, NCPDP Uu~Daw 0 Cannot Be Submitted Ms Drug W/Avail Generics~50740~Error List Daw0 Cant Be Submit Ms Drug W/Avail Gen. Prescriber has indicated the brand name drug is medically necessary. It is used when a sender notifies the receiver of drug utilization, drug evaluations, or information on the appropriate selection to process the claim/encounter. Required when needed to uniquely identify the relationship of the patient to the cardholder ID, as assigned by the other payer. RW: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Overrides may be approved after 50% of the medication day supply has lapsed since the last fill. Reversal Window (If transaction is billed today, what is the, Required when needed to match the reversal to the original billing transaction. All products in this category are regular Medical Assistance Program benefits. Required when a product preference exists that needs to be communicated to the receiver via an ID. Caremark Only members have the right to appeal a PAR decision. Provided for informational purposes only. A PAR must be submitted by contacting the Pharmacy Benefit Manager Support Center. NCPDP EC 8K-DAW Code Not Supported and return the supplemental message Submitted DAW is supported with guidelines. Figure 4.1.3.a. Drugs that are considered regular Health First Colorado benefits do not require a prior authorization request (PAR). Please resubmit with appropriate DAW code: 1-prescriber requests brand, contact MRx at 18004245725 for override. Download Standards Membership in NCPDP is required for access to standards. DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE. Providers must submit accurate information. The use of inaccurate or false information can result in the reversal of claims. The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Pharmacies may call the Pharmacy Support Center to request a quantity limit override if the medication is related to the treatment or prevention of COVID-19, or the treatment of a condition that may seriously complicate the treatment of COVID-19. WebIts content included administrative items and other artifacts for Centers for Medicare & Medicaid Services (CMS) Quality Reporting Programs, State all-payer claims databases (APCDs), Children's Electronic Health Record (EHR) Format, and Agency for Healthcare Research and Quality (AHRQ) Patient Safety Common Formats, as well as standards for Required if needed to identify the transaction. Required if this value is used to arrive at the final reimbursement. Sent if reversal results in generation of pricing detail. DESI drugs ** [applies to drugs with a Covered Outpatient Drug (COD) status equal to DESI - 5 (LTE/IRS drug for all indications or DESI 6 LTE/IRS drug withdrawn from market)]. Pharmacies can submit these claims electronically or by paper. Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required when a repeating field is in error, to identify repeating field occurrence. Pharmacy The following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. Reimbursable Basis Definition The following NCPDP fields below will be required on 340B transactions. For DAW 8-generic not available in marketplace or DAW 9-plan prefers brand product, refer to the Colorado Pharmacy Billing Manual", Allowed by Prescriber but Plan Requests Brand. Substitution Allowed - Pharmacist Selected Product Dispensed, NCPDP 22-M/I DISPENSE AS WRITTEN CODE~50021~ERROR LIST M/I DISPENSE AS WRITTEN CODE and return the supplemental message Submitted DAW code not supported. A PAR approval does not override any of the claim submission requirements. Instructions for Completing the Pharmacy Claim Form - update to Prescriber ID, ID Qualifier and Product ID Qualifier. endstream endobj 1711 0 obj <>>>/Filter/Standard/Length 128/O(V^TpFH<1b,pdk%{ \rL)/P -1052/R 4/StmF/StdCF/StrF/StdCF/U(Z6r>H8 )/V 4>> endobj 1712 0 obj <>/Metadata 104 0 R/Outlines 447 0 R/PageLayout/OneColumn/Pages 1702 0 R/StructTreeRoot 608 0 R/Type/Catalog>> endobj 1713 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1714 0 obj <>stream WebBASIS OF REIMBURSEMENT DETERMINATION: Required when Ingredient Cost Paid (506-F6) is greater than zero (0). Required when any other payment fields sent by the sender. Claim Billing Accepted/RejectedMaximum Count of 3 Field # 355NT 3385C3396C347C991MH 356NU992MJ142UV143UW 144UX 145UY Response Coordination of Benefits/Other Payers SegmentSegment Identification (111AM) = 28 NCPDP Field Name OTHER PAYER ID COUNT The value of '05' (Acquisition) or '08' (340B Disproportionate Share Pricing/Public Health Service) in the Basis of Cost Determination field (NCPDP Field # 423-DN). Enrolled Medicaid fee-for-service (FFS) members may receive their outpatient maintenance medications for chronic conditions through the mail from participating pharmacies. Required if needed to provide a support telephone number to the receiver. 19 Antivirals Dispensing and Reimbursement This will allow the pharmacist to determine if the medication was prescribed in relation to a family planning visit (e.g., tobacco cessation, UTI and STI/STD medications). If a member has Medicaid as their secondary insurance and their primary insurance covers a medication, but Health First Colorado requires a prior authorization for the medication, the pharmacy or provider may request a prior authorization override by contacting the Magellan Helpdesk at 1-800-424-5725. If a pharmacy disagrees with the final decision of the pharmacy benefit manager, the pharmacy may file an appeal with the Office of Administrative Courts. The total service area consists of all properties that are specifically and specially benefited. DESI drugs and any drug if by its generic makeup and route of administration, it is identical, related, or similar to a less than effective drug identified by the FDA, Drugs classified by the U.S.D.H.H.S. The number of authorized refills must be consistent with the original paid claim for all subsequent refills. Health First Colorado is the payer of last resort. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. CMS began releasing RVU information in December 2020. Purchaser shall compensate Manufacturer for any such additional services on an Expense Reimbursement Basis. WebThese CPT codes are not used under Medicare Part B, but may be used by Medicaid, private health insurers, or Medicare Part D plan administrators in determining reimbursement for MTM services. Notification of PAR approval or denial is sent to each of the following parties: In addition to stating whether the PAR has been approved or denied, a PAR denial notification letter is sent to members. A pharmacist shall not be required to counsel a member or caregiver when the member or caregiver refuses such consultation. Required if needed to match the reversal to the original billing transaction. *Note: Code 09 is a negative amount and is not a valid option for field 351-NP. An additional request for reconsideration may be submitted within 60 days of the reconsideration denial if information can be corrected or if additional supporting information is available. Pharmacies may submit claims electronically by obtaining a PAR from thePharmacy Support Center. Required for partial fills. If the reconsideration is denied, the final option is to appeal the reconsideration. OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT, Required for all COB claims with Other Coverage Code of 2 or 4. WebIn a physical inventory model, a prescription for an Eligible Patient could be filled partially with drugs from the Section 340B inventory and partially with drugs from the non-Section 340B inventory for such reasons as inventory shortage, short Express Scripts For non-mail order transactions, there is a maximum 20-day accumulation allowed every rolling 180 days. Required - If claim is for a compound prescription, list total # of units for claim. Required when the sender (health plan) and/or patient is tax exempt and exemption applies to this billing. Commercial payers must use standards defined by the U.S. Department of Health and Human Services (HHS) but are largely regulated state-by-state. The Department has determined the final cost of the brand name drug is less expensive and no clinical criteria is attached to the medication. %PDF-1.6 % Companion Document To Supplement The NCPDP VERSION The "Dispense as Written (DAW) Override Codes" table describes valid scenarios allowable per DAW code. WebBASIS OF REIMBURSEMENT DETERMINATION RW: Required if Ingredient Cost Paid (506-F6) is greater than zero (0). iT|'r4O!JtN!EIVJB yv7kAY:@>1erpFBkz.cDEXPTo|G|r>OkWI/"j1;gT* :k $O{ftLZ>T7h.6k>a'vh?a!>7 s A compounded prescription (a prescription where two or more ingredients are combined to achieve a desired therapeutic effect) must be submitted on the same claim. Required for the partial fill or the completion fill of a prescription. Required if Patient Pay Amount (505-F5) includes coinsurance as patient financial responsibility. All other drugs in the Compound Segment will be assigned a KQ modifier by Medicare during processing to ensure proper completion of the claim. Family planning (e.g., contraceptives) services are configured for a $0 co-pay. Prescription cough and cold products include non-controlled products and guaifenesin/codeine syrup formulations (i.e. Required if utilization conflict is detected. Webb) A Basis of Cost Determination value of 08 (340B Disproportionate Share Pricing) indicates the drugs that are to be paid at the pharmacys 340B drug acquisition cost c) The drugs Actual Acquisition Cost must be entered into the Submitted Ingredient Cost field BASIS Additionally, the drug may be subject to existing utilization management policies as outlined in the Appendix P, PDL, or Appendix Y. Required when the Other Payer Reject Code (472-6E) is used. Required when needed to identify the transaction. Updated Partial Fill Section to read Incremental Fills and/or Prescription Splitting, Updated Quantity Prescribed valid value policy, Updated the diagnosis codes in COVID-19 zero copay section. No blanks allowed. Required if needed by receiver to match the claim that is being reversed. These medications (e.g., Paxlovid) still need to be billed to Colorado Medicaid, even though they are free of cost, and the claim requirements for billing free medications is outlined below: The Health First Colorado program uses the National Council on Prescription Drug Programs (NCPDP) electronic format and the Pharmacy Claim Form (PCF) to submit prescription drug claims. Claim Billing Accepted/RejectedMaximum Count of 3 Field # 355NT 3385C3396C347C991MH 356NU992MJ142UV143UW 144UX 145UY Response Coordination of Benefits/Other Payers SegmentSegment Identification (111AM) = 28 NCPDP Field Name OTHER PAYER ID COUNT WebBasis of Reimbursement Determinationis an optional field that can be returnedon a paid or duplicatebilling transaction. For Transaction Code of "B1", in the Claim Segment, the Prescription/Service Reference Number Qualifier (455-EM) is "1" (Rx Billing). Required when this value is used to arrive at the final reimbursement. Requests for Reconsideration must be filed in writing with the pharmacy benefit manager within 60 days of the most recent claim or prior reconsideration denial. Exclusions: Updated list of exclusions to include compound claims regarding dual eligibles. One of the other designators, "M", "R" or "RW" will precede it. Treatment of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Non-maintenance products submitted by a pharmacy for mail-order prescriptions will deny. The Health First Colorado program restricts or excludes coverage for some drug categories. Required when Basis of Cost Determination (432-DN) is submitted on billing. Required if text is needed for clarification or detail. Mental illness as defined in C.R.S 10-16-104 (5.5). A member has tried the generic equivalent but is unable to continue treatment on the generic drug and criteria is met for medication. All pharmacy PARs must be telephoned, faxed, or submitted via Real Time Prior Authorization via EHR, by the prescribing physician or physician's agent to the Pharmacy Benefit Manager Support Center. Web*Basis of Reimbursement Determination (522-FM) is 14 (Patient Responsibility Amount) or 15 (Patient Pay Amount) unless prohibited by state/federal/regulatory agency. Required if Basis of Cost Determination (432-DN) is submitted on billing. Member Contact Center1-800-221-3943/State Relay: 711. Coordination of Benefits/Other Payments Count, Required if Other Payer ID (Field # 340-7C) is used, Required if identification of the Other Payer Date is necessary for claim/encounter adjudication, CCYYMMDD. Enrolling in Health First Colorado as an OPR provider: If an OPR prescriber does not wish to enroll with Health First Colorado they must refer their patients to an enrolled prescriber, otherwise claims will deny. Effective 10/22/2021, Updated policy for Quantity Limit overrides in COVID-19 section. B. WebReimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes. PB 18-08 340B Claim Submission Requirements and Required when there is a known patient financial responsibility incentive amount associated with the Preferred Product ID (553-AR) and/or Preferred Product Description (556-AU). All Health First Colorado providers are required to use tamper-resistant prescription pads for written prescriptions. Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational Required if Other Payer ID (340-7C) is used. These will be handled on a case-by-case basis by the Pharmacy Support Center if requested by a Health First Colorado healthcare professional (i.e. Nursing facilities must furnish IV equipment for their patients. This requirement stems from the Social Security Act, 42 U.S.C. For TXIX, if the prescriber confirms that the drug was not prescribed in relation to a family planning visit, then the pharmacy should remove the 6-Family Plan from the claim so that the claim can adjudicate accordingly. Helps to ensure that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately. Members of these eligibility categories will be subject to utilization management policies as outlined in the Appendix P, PDL or Appendix Y. %%EOF Required for this program when the Other Coverage Code (308-C8) of "3" is used. 12 = Amount Attributed to Coverage Gap (137-UP) The Department does not pay for early refills when needed for a vacation supply. Health First Colorado is temporarily deferring medication prior authorization (PA) requirements for members on all medications for which there is an existing 12-month PA approval in place. "P" indicates the quantity dispensed is a partial fill. Pharmacies may request an early refill override for reasons related to COVID-19 by contacting the Pharmacy Support Center. %PDF-1.5 % Incremental and subsequent fills may not be transferred from one pharmacy to another. Effective February 25, 2017, pharmacies must code their systems using the D.0 Payer Sheets provided below when submitting pharmacy POS transactions to the Health First Colorado program for payment. Representation by an attorney is usually required at administrative hearings. Pharmacy Required when the receiver must submit this Prior Authorization Number in order to receive payment for the claim. Required if Approved Message Code Count (547-5F) is used and the sender needs to communicate additional follow up for a potential opportunity. The field has been designated with the situation of "Required" for the Segment in the designated Transaction. WebExamples of Reimbursable Basis in a sentence. The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.0. A detailed description of the extenuating circumstances must be included in the Request for Reconsideration (below). WebIts content included administrative items and other artifacts for Centers for Medicare & Medicaid Services (CMS) Quality Reporting Programs, State all-payer claims databases (APCDs), Children's Electronic Health Record (EHR) Format, and Agency for Healthcare Research and Quality (AHRQ) Patient Safety Common Formats, as well as standards for Response DUR/PPS Segment Situational Response Prior Authorization Segment Situational